A decade-long decline in benzodiazepine prescriptions for older Americans ground to a halt just as the COVID-19 pandemic swept across the country, with prescribing actually rebounding in the most vulnerable subgroups—adults aged 75 and older and those receiving medications through long-term care pharmacies. The findings, drawn from a sweeping analysis of nearly 25 million patients and published in the Annals of Internal Medicine, raise fresh concerns that the pandemic disrupted hard-won gains in medication safety for a population especially susceptible to the drugs’ harms.
Benzodiazepines—among them alprazolam, lorazepam, and diazepam—are positive allosteric modulators of the GABA-A receptor, enhancing inhibitory neurotransmission to produce sedation, anxiolysis, and muscle relaxation. While effective for acute anxiety and insomnia, their use in geriatric populations is fraught with danger. Age-related changes in pharmacokinetics and pharmacodynamics, including reduced hepatic clearance and increased receptor sensitivity, amplify the risk of falls, hip fractures, cognitive decline, and motor vehicle collisions. Clinical guidelines have long recommended that these agents be prescribed to older adults only at the lowest effective dose for the shortest possible duration, if at all. Yet they remain stubbornly common.
The new study, led by Mark Olfson, professor of epidemiology at Columbia University Mailman School of Public Health and professor of psychiatry at Columbia Vagelos College of Physicians and Surgeons, set out to track national prescribing patterns from January 2015 through December 2024. The researchers leveraged IQVIA Longitudinal Prescription Claims, a dataset capturing more than 90 percent of U.S. retail pharmacy prescriptions and roughly 75 to 80 percent of long-term care pharmacy dispensing. They identified all adults aged 65 and older who filled at least one benzodiazepine prescription during the study window, yielding a cohort of almost 25 million individuals, about two-thirds of whom were women.
What they found was a tale of two eras. From 2015 up to early 2020, benzodiazepine prescribing rates trended steadily downward, consistent with years of educational campaigns, deprescribing initiatives, and heightened awareness of the Beers Criteria for potentially inappropriate medication use in older adults. But when the pandemic struck, the decline stopped. Overall prescribing remained below 2015 levels, but the downward momentum vanished. Moreover, in the oldest old—those aged 75 years and above—and among patients whose prescriptions were dispensed through long-term care pharmacies, rates actually ticked upward after 2020.
The authors cannot pinpoint a single cause from the prescription records alone, but they point to a confluence of pandemic-era disruptions that plausibly drove the shift. Social isolation intensified anxiety and insomnia in countless older adults, while nursing homes and assisted living facilities faced severe staffing shortages that may have reduced the capacity to provide non-pharmacologic interventions such as cognitive behavioral therapy, structured activities, or increased personal attention. At the same time, access to outpatient behavioral health services contracted, leaving clinicians with fewer tools beyond the prescription pad. Previous studies have already documented worsening depressive symptoms and greater reliance on psychotropic medications among nursing home residents during the same period, reinforcing the notion that the pandemic eroded the scaffolding of geriatric mental health care.
The clinical implications are sobering. Benzodiazepine-associated adverse events—particularly falls and fractures—carry enormous morbidity in the very old, often precipitating a cascade of functional decline, hospitalization, and loss of independence. Older adults in long-term care are especially fragile, typically managing multiple chronic conditions and taking numerous drugs whose interactions with benzodiazepines can compound sedation and cognitive clouding. A rise in prescribing within that group represents a direct threat to patient safety.
Olfson emphasizes that the study should not be read as an indictment of prescribing during a crisis but rather as a call to renew focus on medication stewardship. “Regular medication reviews and greater access to effective non-pharmacologic treatments may help reduce unnecessary benzodiazepine use while ensuring that patients continue to receive appropriate care,” he said. Structured deprescribing programs, telehealth-delivered cognitive behavioral therapy for insomnia, and quality improvement collaboratives in long-term care settings are among the strategies that could help recapture the pre-pandemic trajectory.
The research team, which included collaborators from Rutgers University, stresses that the post-2020 stagnation transcends mere statistical noise; it represents a persistent change in trend that has outlasted the acute phase of the pandemic. With the nation’s over-65 population projected to grow substantially in the coming years, and with long-term care pharmacy data showing the most concerning signals, the findings underscore an urgent need to refocus medication safety efforts on those least able to tolerate the drugs’ side effects.
The study serves as a powerful reminder that public health gains are not self-sustaining. Even well-established improvements in prescribing practice can be derailed by systemic shocks, and rebuilding them requires intentional, evidence-based effort. As Olfson and colleagues conclude, adults aged 75 and older and those receiving long-term care should remain priority populations for initiatives that ensure the right medications reach the right patients at the right time.
Subject of Research: Trends in benzodiazepine prescribing to older adults before and after the COVID-19 pandemic
Article Title: Benzodiazepine Prescriptions to Older Adults in the United States, 2015 to 2024
News Publication Date: Not provided
Web References: 10.7326/ANNALS-25-05594
References: Annals of Internal Medicine, DOI: 10.7326/ANNALS-25-05594
Image Credits: Not provided
Keywords: benzodiazepines, older adults, COVID-19, prescribing trends, long-term care, medication safety, deprescribing, geriatric pharmacology
